Story & anti-storyhttp://storyandantistory.org
Language as art / as behaviorSun, 07 Dec 2014 16:32:17 +0000enhourly1http://wordpress.org/?v=3.2.1Review of Anatomy Of An Epidemic: This is your brain on psychiatric drugshttp://storyandantistory.org/2011/09/review-of-anatomy-of-an-epidemic-this-is-your-brain-on-psychiatric-drugs/
http://storyandantistory.org/2011/09/review-of-anatomy-of-an-epidemic-this-is-your-brain-on-psychiatric-drugs/#commentsMon, 26 Sep 2011 18:10:13 +0000RBhttp://storyandantistory.org/?p=848 [...]]]>Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

by Robert Whitaker

Crown, 404 pp., $26.00

About three-quarters of the way through Robert Whitaker’s expose of the psychiatric drug industry, Anatomy Of An Epidemic, I found myself beginning to worry. Whitaker’s claim is that contrary to what we have been told, psychiatric medications actually cause far more mental illness than they cure. Chapter by chapter, he had built a damning case at which to nod and wince—but now I was neck-deep in the chapter on antidepressants, and I was no longer nodding but reading with concern.

For several years back in my 30s, I had sought desperately for an antidepressant that would “cure” me of my longstanding depression and associated shyness; that would, as psychiatrist and author Peter Kramer infamously wrote in his own book, Listening To Prozac, make me “better than well.” I had tried and flunked not just Prozac, but a half-dozen other antidepressants, often combined with other psychoactive drugs that psychiatrists believed might “potentiate” the antidepressant effect: lithium, synthetic thyroid, speed (Dexedrine), an anti-narcolepsy drug (Provigil), bromocriptine, naltrexone, Depakote, amantadine. None of these drugs or drug combinations ever succeeded in doing much more than ruin my sleep, and I had long ago given up the quest for a magic bullet in favor of the quieter avenues of talk therapy. Yet now I found myself wondering: in those few years of drug experimentation, had I inadvertently made myself more rather than less vulnerable to future bouts of depression? Had I in fact damaged my brain, as the studies cited in the chapter I was now reading implied was a very real possibility?

I’ll most likely never know. And in fact, I’m not all that worried. The greatest danger of brain damage, the book asserts, is for persons who are “maintained” by their doctors not just intermittently, but continuously for many years on antidepressants or other psychiatric medications. The conventional wisdom is that maintenance in this manner helps prevent relapse back into depression—or back into schizophrenia, if one is taking antipsychotics; or back into anxiety, if one is taking an “antianxiety” medication such as Xanax. After reading Anatomy Of An Epidemic, I am thankful that I am not being maintained in this manner. I do not have to worry if the antidepressant I am taking every day is accelerating cell death in the hippocampus, an area of the brain important for mood and memory; or if the antipsychotic I am taking is causing my frontal lobes to shrink, eventually giving me what amounts to a drug-induced lobotomy; or if my antianxiety medication is destroying brain receptors in such a way as to possibly make my anxiety symptoms permanent.

Enough preamble; let’s talk about the book itself. In Anatomy Of An Epidemic we have a message that is deliberately alarming; that goes out of its way to deconstruct and debunk what we have been told for decades not only by the pharmaceutical industry and by psychiatry as a profession, but by our most trusted news sources on mental health issues—e.g. science-friendly publications such as TIME magazine and the New York Times. [1] So you may well ask: with the media and medical establishments firmly in favor of psychiatric drugs, is Whitaker’s book worth reading, or merely an alarmist screed?

This question is less rhetorical than it may seem. In fact, for many people it could be a very threatening question if taken seriously. Let us say that you take psychiatric medications yourself, or that your spouse or partner or child takes them; if so, you might very well be forced by reading Anatomy Of An Epidemic to consider a decision you would rather not have to make—namely, whether to take yourself or your kids off the drugs to minimize or hopefully reverse what may already be a process of progressive incapacity, slow at first, not so slow later on. There would be some major downsides to quitting: for one, the possibility of feeling very sick mentally and physically until your brain and body hopefully healed; for another, the need to negotiate alternative social support or therapy in the absence of drugs; and then finally, the fact that you would be holding a decidedly minority view on the topic, with everyone from family to doctors saying you were crazy and making a mistake.

So—if you or someone you love is indeed on medication, you may even at this moment be weighing such potential downsides in your mind, and concluding that it is easier to skip this book and keep going with the drugs. You may rationalize that after all, every drug has its side effects, but the short-term benefits are so clear (in your case, or in your children’s case, etc.) that it is worth it. And besides, why should we not trust our best news institutions to tell us the truth? Why listen to some crank who insists we are in peril, when he might be wrong?

Yet I urge you to reconsider and read Anatomy of An Epidemic anyway, even with all the doubts your mind can muster. And I will devote the rest of this review to reasons why. Most of what I say will be picking through highlights from the book, but even these highlights should serve to illustrate the cogency and thoroughness of Whitaker’s reporting and reasoning. And they should illustrate as well why you should not, in fact, necessarily trust large news organizations to know what they are talking about. And not automatically trust your shrink or your GP on this issue, either, if they are of the conventional thinking. Please note that I will discuss objections to the book’s thesis near the end of the review, so it will not be unbalanced in that regard.

A paradox leads to a challenge

At heart, Whitaker’s challenge to conventional wisdom is simple. Two mental-health booms have coincided in the U.S. since the 1950s: a boom in severe mental illness, and a boom in the invention and prescription of psychiatric drugs that supposedly treat these illnesses with great success. It’s a clear paradox. Shouldn’t the invention of new and better drugs see a decline in rates of mental illness, not an increase? One possibility would be that the true rate of mental illness is more or less the same, but more people are getting diagnosed than ever before thanks to changes in societal standards and improved outreach. Another possibility would be that societal problems such as the loss of the extended family have increased, thereby making it harder for mentally fragile people to find the support they once enjoyed outside of institutions and drugs. Such arguments may have some merit, but Whitaker asserts that clean data collected since the 1970s and 1980s suggests there is an additional dynamic going on that cannot be explained in this way. In fact, he says, these figures clearly show a dramatic increase in the real rate of severe mental illness in this country.

And this double boom in both drugs and mental illness is not the only paradox. Another is illustrated by a series of studies by the World Health Organization. These studies have found that outcomes for schizophrenia, an especially difficult mental illness, are much better in poor countries like Nigeria and India than in rich countries like the U.S. In poor countries, most schizophrenia patients over a period of years recover and return to work; in rich countries, the opposite is true: most never recover, and most never return to work. Why might this be? It is worth quoting Whitaker at length here, to show the pains he takes in his reporting and reasoning:

Although the WHO investigators didn’t identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries. Moreover, in Agra, India, where patients arguably fared the best, only 3 percent of the patients were kept on an antipsychotic. Medication usage was highest in Moscow, and that city had the highest percentage of patients who were constantly ill.

Whitaker sets up his argument with these and similar paradoxical figures. There are two possibilities, he tells us: either psychiatric drugs really do work as advertised, helping people recover from severe mental illness and stay recovered; or they don’t work as advertised, but instead make people worse. Either way, he suggests, long-term outcome data for affected persons in the U.S. ought to reflect what is happening. Either outcomes will be better with drugs, or they will be worse with drugs. And with that he invites us to follow us into the body of the book, where we will learn how these drugs were discovered, how they have been marketed, and how they have actually affected the lives of people taking them—and taking them not just for a few weeks or months, as required for a typical drug company study, but for the years and decades that constitute maintenance in conventional psychiatric treatment.

[1] It is worth noting that the Times did not review the book, but did choose to give op-ed space to Peter Kramer so that Kramer could rebut the positive review of the book that appeared in The New York Review of Books. (I noted that positive review in an earlier post on this site, which you can find here.) And although TIME on the other hand did review the book, the review was a single back-page paragraph. This can be compared to the news features TIME regularly runs on mental illness in which drugs are a key component of treatment: see for example the last page of Health Checkup: Kids and Mental Health, Oct. 21, 2010, which virtually mandates drug treatment for bipolar children—a tactic Whitaker argues leads to worse outcomes for children as surely as it does for adults. ↩

]]>http://storyandantistory.org/2011/09/review-of-anatomy-of-an-epidemic-this-is-your-brain-on-psychiatric-drugs/feed/1Hineline bicycle quotehttp://storyandantistory.org/2011/07/646/
http://storyandantistory.org/2011/07/646/#commentsTue, 19 Jul 2011 17:50:26 +0000RBhttp://storyandantistory.org/?p=646Most of us know how to ride bicycles and know that we know how to ride bicycles, without knowing how we know how to ride bicycles. (Philip Hineline, “A self-interpretive behavior analysis”)
]]>http://storyandantistory.org/2011/07/646/feed/0Special quote: Carol Bly on ignorancehttp://storyandantistory.org/2011/07/special-quote-carol-bly-on-ignorance/
http://storyandantistory.org/2011/07/special-quote-carol-bly-on-ignorance/#commentsMon, 04 Jul 2011 11:29:19 +0000RBhttp://storyandantistory.org/?p=594Writers do the hard psychological work of trying not to be ignorant. (Carol Bly, Beyond the Writers’ Workshop)
]]>http://storyandantistory.org/2011/07/special-quote-carol-bly-on-ignorance/feed/0Special quote: Robert Roothttp://storyandantistory.org/2011/07/special-quote-robert-root/
http://storyandantistory.org/2011/07/special-quote-robert-root/#commentsMon, 04 Jul 2011 11:28:31 +0000RBhttp://storyandantistory.org/?p=592I suspect that language was developed to serve the needs of observed, perceived, or recollected experience—the nonfiction motive. For example, “There are wooly, mammoth creatures at the waterhole.” Or: “Let me explain how your mate was gored by a wooly mammoth.” (Robert L. Root Jr., The Nature of Nonfiction)
]]>http://storyandantistory.org/2011/07/special-quote-robert-root/feed/0Special quote: Törneke from Learning RFThttp://storyandantistory.org/2011/07/special-quote-torneke-from-learning-rft/
http://storyandantistory.org/2011/07/special-quote-torneke-from-learning-rft/#commentsMon, 04 Jul 2011 11:25:59 +0000RBhttp://storyandantistory.org/?p=590All through life, it will be easier to describe to others how we go about driving a car or painting a picture than it will be to describe how we do our thinking or how we feel when we are sad. (Niklas Törneke, Learning RFT)
]]>http://storyandantistory.org/2011/07/special-quote-torneke-from-learning-rft/feed/0Plot twist in the story about antidepressants?http://storyandantistory.org/2011/07/the-story-about-antidepressants-the-plot-thickens/
http://storyandantistory.org/2011/07/the-story-about-antidepressants-the-plot-thickens/#commentsSun, 03 Jul 2011 12:45:37 +0000RBhttp://storyandantistory.org/?p=578 [...]]]>It occurs to me that we can think of the massive use of antidepressants and similar drugs in this country as involving a kind of story: depression is caused by such-and-such, the drugs will cure it by such-and-such an action, and everything is groovy. So say the drug companies in their TV ads; so hope the GPs and psychiatrists who prescribe the drugs to their patients with crossed fingers. And so hope the patients. I have close friends who, when the subject of this or that mental illness comes up, can be counted on to repeat the mantra of the drug companies: “It’s an imbalance in brain chemistry.”

But now here we are 40 years later, with perhaps ten percent of American adults taking an antidepressant, and researchers are writing about “oppositional tolerance,” and drug-induced “tardive dysphoria.” That is surely a health outcomes story that needs to investigated, and if we want to put this into an even sharper moral context, we need only consider this: Many teenagers are now being prescribed an antidepressant, and when they take the drug, their brains will develop “oppositional tolerance” to it. What percentage of these youth will end up with drug-induced tardive dysphoria, and thus suffer a lifetime of chronic depression?

Many people are already leery of the antidepressants they feel they must take. If word spreads of studies like these, I can imagine all hell breaking loose. But what narrative will patients choose to replace the current one? And where will they turn if not to drugs?

]]>http://storyandantistory.org/2011/07/the-story-about-antidepressants-the-plot-thickens/feed/0Good article on Marsha Linehan, creator of Dialectical Behavior Therapyhttp://storyandantistory.org/2011/06/good-article-on-marsha-linehan-creator-of-dialectical-behavior-therapy/
http://storyandantistory.org/2011/06/good-article-on-marsha-linehan-creator-of-dialectical-behavior-therapy/#commentsThu, 23 Jun 2011 14:48:42 +0000RBhttp://storyandantistory.org/?p=552 [...]]]>Linehan is of the giants of modern talk therapy; in creating Dialectical Behavior Therapy, she went well beyond conventional CBT by including mindfulness and acceptance components, thereby more effectively reaching many people in deep distress about who they feel themselves to be. This article in the New York Times is a particularly nice celebration of her life work:

]]>http://storyandantistory.org/2011/06/good-article-on-marsha-linehan-creator-of-dialectical-behavior-therapy/feed/1Psychiatric medications as super-placeboshttp://storyandantistory.org/2011/06/meds-as-super-placebos/
http://storyandantistory.org/2011/06/meds-as-super-placebos/#commentsWed, 08 Jun 2011 20:07:34 +0000RBhttp://storyandantistory.org/?p=524 [...]]]>This isn’t directly related to my interest in the psychological aspects of language as behavior, but it does bear on the question of why humans suffer psychologically in the first place, and on how such suffering should best be treated: a review in The New York Review of Books of three books on what seems to be the con game of psychiatric medication.

The review is titled The Epidemic of Mental Illness: Why? and the books involved are The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, Basic Books, 226 pp., $15.99 (paper); Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Crown, 404 pp., $26.00; and Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis, by Daniel Carlat, Free Press, 256 pp., $25.00.

The reviewer herself, Marcia Angell, is bylined as former editor in chief of The New England Journal of Medicine, so it would be hard to argue that she is a naive audience for the topic. Although the review is already online, it is forward-dated to the June 23 issue of the magazine; it is billed as the first of two parts, so we must wait till the second installment arrives to find out exactly where Angell stands. From what she has written so far, though, she seems extremely sympathetic to the anti-medication arguments in all three books. If you are at all interested, you should read the review yourself; but here are a few snippets that I find particularly arresting.

When it was found that psychoactive drugs affect neurotransmitter levels in the brain, as evidenced mainly by the levels of their breakdown products in the spinal fluid, the theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. For example, because Thorazine was found to lower dopamine levels in the brain, it was postulated that psychoses like schizophrenia are caused by too much dopamine. Or later, because certain antidepressants increase levels of the neurotransmitter serotonin in the brain, it was postulated that depression is caused by too little serotonin . . .

. . . the main problem with the theory is that after decades of trying to prove it, researchers have still come up empty-handed. All three authors document the failure of scientists to find good evidence in its favor. Neurotransmitter function seems to be normal in people with mental illness before treatment.

And what about the anecdotal trump card we can all pull out, of our friend or relative who says that in their dark hours, it was an antidepressant that helped them more than anything else? According to the review, one of the authors, Irving Kirsch, is a psychologist at the University of Hull in the UK; he has been studying antidepressants for 15 years, and has come to the conclusion that they are essentially a kind of super-placebo: because they exhibit detectable side-effects, they convince the persons taking them of their benefits. In other words, if the side-effects did not occur, it seems very possible that the persons taking the drugs would not know to feel better. Angell summarizes Kirsch’s argument on this point this way:

[He] was also struck by another unexpected finding. In his earlier study and in work by others, he observed that even treatments that were not considered to be antidepressants—such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies—were as effective as antidepressants in alleviating the symptoms of depression. Kirsch writes, “When administered as antidepressants, drugs that increase, decrease or have no effect on serotonin all relieve depression to about the same degree.” What all these “effective” drugs had in common was that they produced side effects, which participating patients had been told they might experience . . .

He suggests that the reason antidepressants appear to work better in relieving severe depression than in less severe cases is that patients with severe symptoms are likely to be on higher doses and therefore experience more side effects.

I wonder if this also might explain the widespread phenomenon of “poop-out,” in which a medication that had seemed helpful suddenly stops working. A placebo effect only lasts for so long before life intrudes again.

]]>http://storyandantistory.org/2011/06/meds-as-super-placebos/feed/0A word about storieshttp://storyandantistory.org/2011/06/a-word-about-stories/
http://storyandantistory.org/2011/06/a-word-about-stories/#commentsTue, 07 Jun 2011 11:36:54 +0000RBhttp://storyandantistory.org/?p=492 [...]]]>This blog combines two interests of mine that are unrelated—except that they both involve analyses of story-telling. I don’t pretend that they belong together. I am putting them side by side, post by post, on an irregular basis, simply to see what happens.

The first of these interests is fairly conventional: how and why do the stories found in personal essays, short stories, novels, plays, and films either work to enchant us or else fail to do so? Close readings are a good way of finding answers. I do them not pedantically but for pleasure. I also do them sometimes for work, as part of teaching essay-writing to adult students at New York University. But I would do close readings anyway even if I didn’t teach.

My second interest is psychological, more specifically behavioral; and it is not conventional at all. It has to do with the stories we tell ourselves about our identity and about the world around us, and how these sometimes limit us more than is necessary. We can learn if we wish to see through our personal myth-making rather than let it dictate our behavior—hence my coining of “anti-story.” This is not a simple subject but quite tricky and sometimes quite technical; and it is one I did not originate but am learning about from others. For an initial and very sketchy orientation, see a word about language as behavior.

–Randy Burgess

]]>http://storyandantistory.org/2011/06/a-word-about-stories/feed/0A note about language as behaviorhttp://storyandantistory.org/2011/06/a-note-about-language-as-behavior/
http://storyandantistory.org/2011/06/a-note-about-language-as-behavior/#commentsTue, 07 Jun 2011 11:34:20 +0000RBhttp://storyandantistory.org/?p=496 [...]]]>My interest in language as behavior (rather than as we normally think of it, as something that simply describes the world) began quite abruptly back in early 2005. That was when I discovered a relatively new kind of talk therapy, Acceptance and Commitment Therapy, or ACT.

ACT was founded sometime in the late 1980s by psychologist Steven Hayes and a handful of close colleagues, but didn’t get much in the way of mainstream notice until starting in 2005, the same year I came across it. In February of that year TIME ran a feature on Hayes; and exactly 12 months later, Salon ran a Q and A interview. Both articles are worth reading, even though both get a great deal wrong—not a surprise when you consider the difficulty of explaining in words that words are not what they say they are.

In one sense, the purpose of ACT is as mundane as it is for most psychotherapies: to help people seeking relief from depression, anxiety, and similarly labeled mental health syndromes. But ACT’s means of doing so is radical, and includes among other things the tearing down of the central assumption of Western psychotherapy that mental illness is a disease state, the opposite of which is “normality.” Instead, like Buddhism, ACT asserts that human suffering is ubiquitous, brought on by conceptual thinking (i.e. “language”) that masquerades as reality. Thus the ultimate goal is not mere symptom relief, but liberation.

But where Buddhism is traditional and spiritual, ACT is science-based, heir among other things to the school of radical behaviorism espoused by B.F. Skinner. And where Buddhist techniques are slow and diffuse, some ACT techniques are quite quick. Overall the therapy resembles other brief talk therapies in that it can help many problems in a dozen or less meetings between therapist and client.

I’m an advocate of ACT even for people who don’t need therapy, yet occasionally get hung up in one area or another. From a “doing” point of view, ACT can be simple once you get it. On the other hand, the theory involved is difficult to explain, even to folks who meditate or follow other mindfulness-related pursuits, such as yoga. ACT isn’t meditation, and it isn’t just mindfulness, although mindfulness is a crucial component. The trickiest aspects of ACT, those dealing with language, are actually derived from something called Relational Frame Theory; Hayes and his colleagues developed RFT as a model both to explain ACT and to improve it. You can read a brief account of RFT here; or you can ponder this passage from an unpublished essay of mine (the 67th draft or thereabouts):

Even a kindergartner can tell you that a dime is “bigger” than a nickel, ignoring the physical reality in favor of an arbitrary social agreement. As adults, most of us can’t see thoughts as thoughts, any more than we can see the air we breath. An example of this is our tendency to treat descriptions and evaluations alike. A description such as “This teapot is red” can be checked for truth, that is, for a one-to-one correspondence with reality; an evaluation such as “I am a bad person,” on the other hand, is a blaming statement that has no truth value, only a social function. And yet we spend our lives worrying about whether we’re bad or good people, as if a self-description were as solid as a teapot.

The above is the merest hint of what RFT deals with and should not be taken very seriously. And beyond that, other psychologists outside of RFT are also doing interesting work with language as behavior—for example, Bertram Malle of Brown University has developed an expanded version of the folk theory of mind, dealing with how we create stories to explain the actions of both ourselves and other persons.